A unique fatal case of Waterhouse-Friderichsen syndrome caused by Proteus mirabilis in an immunocompetent subject: Case report and literature analysis

INTRODUCTION

The Waterhouse-Friderichsen syndrome (WFS), also known as purpura fulminans, is a potentially lethal condition described as acute hemorrhagic necrosis of the adrenal glands. It is often caused by infection. Classically, Neisseriae meningitidis represents the main microorganism related to WFS, although, infrequently, also other infectious agents are reported as a possible etiologic agent. The authors report the first case of death due to Proteus mirabilis infection, with postmortem evidence of WFS.

PATIENT CONCERNS

After a facial trauma that provoked a wound on the nose, the subject, a healthy 40-years old man, was conducted to the local hospital (in Sicily, Italy) after the primary care he was discharged. Subsequently, after 2 days of general malaise, he returned to the hospital due to the worsening of the clinical condition. During the hospitalization, hypotension, and neurological impairment appeared; the laboratory analysis showed leukocytosis and the alteration of renal, hepatic and coagulative parameters. Microbiological blood analysis resulted positive for a P mirabilis infection.

DIAGNOSIS

Multiorgan failure (MOF) with disseminated intravascular coagulation (DIC) due to sepsis was diagnosed.

INTERVENTIONS

The practitioners administered intensive support, antibiotic therapy, antithrombin III, vitamin K, and plasma.

OUTCOMES

After 3 days the subject died. The autopsy and the microscopic investigation were performed revealing, also, the adrenal diffuse micronodular hyperplasia associated with a cortico-medullary hemorrhagic apoplexy.

CONCLUSION

To our knowledge, this is the first case of MOF with WFS due to P mirabilis infection. This case report suggests that P mirabilis should be added to the list of unusual bacteria causing WFS. Furthermore, it supports the theory that any bacterium which causes DIC may cause adrenal hemorrhage and should suggest to clinicians the importance to consider a potential adrenal involvement in every patient with sepsis and DIC.

A rare case of Waterhouse- Friderichsen syndrome during primary Varicella zoster infection

Primary Varicella zoster virus infection in adults is associated with a higher risk of complications when compared with the benign disease course of primary infection during childhood. We present a rare complication of adult primary Varicella zoster in the form of acute, irreversible adrenal insufficiency due to bilateral adrenal haemorrhage, which is also known as the WaterhouseFriderichsensyndrome.

A rare case of Waterhouse-Friderichsen syndrome caused by Capnocytophaga canimorsus in an immunocompetent patient

A 53-year-old Caucasian male with hypertension and active tobacco abuse presented to a community hospital with a 2-day history of vague abdominal pain, myalgia and increased lethargy after being bitten on his right hand by the family dog while camping just 3 days prior to symptom onset. He expired within 90 min upon arrival to our intensive care unit. Pre-mortem blood cultures grew a fastidious Gram-negative aerobic rod that was identified as Capnocytophaga canimorsus. Autopsy findings showed multi-organ disseminated intravascular coagulopathy with microthrombi along with bilateral adrenal hemorrhage and necrosis of the adrenal glands consistent with Waterhouse-Friderichsen syndrome. This case contributes to the medical literature as a rare presentation of Capnocytophaga canimorsus infection in an otherwise immunocompetent patient and stresses the importance of a thorough history taking and physical examination by clinicians along with prompt administration of appropriate antibiotics.

Syndrome de Waterhouse-Friderichsen au cours d'une péritonite à Morganella morganii et Enterococcus faecium

About fifty to sixty percent of patients with septic shock acquire acute adrenal insufficiency. This insufficiency is most often relative, but can sometimes be absolute. Bilateral adrenal haemorrhage is a rare aetiology of absolute acute adrenal insufficiency. It is classically described in patients with severe meningococcemia (purpura fulminans), who commonly present many of the risk factors associated with bilateral adrenal haemorrhage (shock, coagulation disorders, sepsis). We report a case of bilateral adrenal haemorrhage during a peritonitis complicated by a septic shock, with no coagulation disorder. This observation shows up that this bilateral adrenal haemorrhage can complicate severe sepsis of various origins, and not only severe meningococcemia. It can be suspected in face of a septic shock with an unfavourable evolution despite adequate treatment.

Spontaneous Waterhouse-Friderichsen syndrome in a gang-housed baboon

Waterhouse-Friderichsen syndrome can cause acute death in the baboon without specific signs. Furthermore, this syndrome could result from stress-related intestinal permeability changes that allow macromolecules and/or microbiological entities to enter the systemic circulation. The resulting sepsis could cause adrenocortical insufficiency, hypotension and shock leading to death.

[A fatal case of overwhelming postsplenectomy infection syndrome developing 10 years after splenectomy]

Splenectomized patients are likely to suffer from severe infections, such as sepsis and meningitis. This syndrome is called overwhelming postsplenectomy infection (OPSI) in Europe and America. The course is rapid, the clinical symptoms are serious, and the prognosis is very poor. We treated one adult patient with OPSI syndrome that developed 10 years after splenectomy.

CASE

A 26-year-old man had undergone a splenectomy following a traffic accident 10 years previously. On January 7, 1996, he had diarrhea and nausea. On January 10, he became drowsy and presented at our hospital with multiple organ failure. He underwent hemodialysis and plasmapheresis because of acute renal failure and also received immune globulin, antibiotics and prednisolone. However, these medications were not effective. He died 7 hours later. We identified diplococcus on a blood smear, IgG 3 deficiency and a low titer of specific pneumococcal IgG 2 antibody. The autopsy findings included bilateral acute hemorrhagic necrosis of the adrenal glands (Waterhouse-Friderichsen syndrome).

Fatal pneumococcal septicemia in a patient with a connective tissue disease

Fulminant pneumococcal sepsis is a rare but life-threatening illness usually occurring in patients with known splenic absence (postsplenectomy) or dysfunction (sickle cell anemia). Several medical illnesses, not typically recognized as being associated with abnormal spleen function, may be complicated by fulminant pneumococcal sepsis. We report a case of fatal pneumococcal sepsis in a patient diagnosed with mixed connective tissue disease who likely had systemic lupus erythematosus and unsuspected splenic fibrosis. Medical illnesses associated with functional asplenia, hematological findings suggesting splenic dysfunction, and confirmatory tests of hyposplenism are discussed.

Lethal Waterhouse-Friderichsen syndrome in posttraumatic asplenia

We herein report a case of fulminant lethal Waterhouse-Friderichsen syndrome in an elderly female patient seven years after posttraumatic splenectomy. In contrast to various reports, this patient had not been vaccinated against Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae, respectively, although infections with these microorganisms are known to cause the main lethal diseases in asplenic patients. Again, we recommend obligatory vaccinations against the mentioned bacteria for it is known that this decreases the risk of fatal septic events in these patients. To optimize prevention, it is imperative to vaccinate patients undergoing splenectomy before discharge from hospital.

Fatal pneumococcal bacteremia with disseminated intravascular coagulation and Waterhouse-Friderichsen syndrome in a vaccinated splenectomized adult. Case report

Fatal pneumococcal bacteremia, disseminated intravascular coagulation and Waterhouse Friderichsen syndrome in a vaccinated, splenectomized adult were caused by serotype 22F (Danish classification), which was not included in the vaccine. Revaccination with a 23-valent pneumococcal vaccine and antibiotic prophylaxis are advocated for patients who have undergone splenectomy.

Waterhouse-Friderichsen syndrome caused by Haemophilus influenzae type b in an immunocompetent young adult

A previously healthy 19-year-old woman had a febrile illness with hypotension, progressive cyanosis, and an evolving petechial rash. Despite aggressive therapy in the face of shock and disseminated intravascular coagulation, the patient suffered a cardiac arrest and could not be resuscitated. Haemophilus influenzae type b was cultured from the blood and echovirus 30 from the cerebrospinal fluid post mortem. Fulminant H influenzae type b infection in an immunocompetent adult is rare but should be recognized as a possible cause of the Waterhouse-Friderichsen syndrome.

[Haemophilus influenzae B meningitis and Waterhouse-Friderichsen syndrome in a 5-month-old infant]

A five months old infant with Waterhouse-Friderichsen syndrome related to Haemophilus influenzae type b meningitis is reported. In spite of treatment with IV fluids, antibiotics and dopamine, he died eight hours after admission. Necropsy findings included bilateral adrenal bleeding compatible with the Waterhouse-Friderichsen syndrome. This is the younger infant reported with this diagnosis in association with Haemophilus influenzae in Chile.

Pneumococcal Waterhouse-Friderichsen syndrome despite a normal spleen

A previously fit 56 year old female presented with a rapidly progressive and fatal pneumococcal septicaemia with disseminated intravascular coagulation. Post-mortem studies confirmed a Waterhouse-Friderichsen syndrome and revealed an anatomically normal spleen; intracellular diplococci were seen within splenic macrophages providing evidence of normal splenic function. This appears to be only the second case of Waterhouse-Friderichsen syndrome due to pneumococcal septicaemia in a patient with a normal spleen.

Overwhelming post-splenectomy infection with Plesiomonas shigelloides in a patient cured of Hodgkin's disease. A case report

The immune deficiencies of Hodgkin's disease persist to some degree even after the patients are clinically cured; these may be amplified by loss of splenic immunologic functions after staging laparotomy and splenectomy. The authors submit a case report wherein a bacterium of relatively low virulence, Plesiomonas shigelloides, was associated with a rapidly fulminant septicemia, disseminated intravascular coagulation, Waterhouse-Friderichsen syndrome, and death in a splenectomized patient free of Hodgkin's disease for approximately five years. This emphasizes the need for prolonged observation, rapid diagnosis, and aggressive intervention in immunocompromised patients, especially those supposedly cured of previous hematologic malignancy.

Waterhouse-Friderichsen syndrome without purpura due to Haemophilus influenzae group B

A second recorded case of Waterhouse-Friderichsen syndrome, without purpura, due to Haemophilus influenzae is described. It is suggested that the absence of purpura should not preclude the diagnosis of the Waterhouse-Friderichsen syndrome due to this organism.

IgM deficiency

Primary isolated IgM deficiency accounted for 0.1% of hospital admissions; secondary IgM deficiency for 2.0%. Although 19% were asymptomatic the rest of 89 subjects (4M:1F) suffered infection (60%), septicemia (36%), atopy (22%), splenomegaly (11%), neoplasia(7%) and autoimmune disorders (3%) with a mortality of 10%. Serious early treatment is needed to avert death from unopposed spread of organisms throughout the blood. Qualitative IgM deficiency (absence of isohemagglutinins) and delayed maturation of IgM can result in similar symptomatology.

Apparent meningococcemia: clinical features of disease due to Haemophilus influenzae and Neisseria meningitidis

To determine the etiology of apparent meningococcemia, all cases of sepsis with coagulopathy, purpura, and/or adrenal hemorrhage (Waterhouse-Friderichsen syndrome) with and without shock occurring over a 12-year period were reviewed. A total of 42 cases were identified; 30 cases were caused by Neisseria meningitidis and 12 cases were caused by Haemophilus influenzae. Compared with patients with disease caused by H influenzae, patients with meningococcal disease were older, more often male, more often contracted the disease in winter-spring, and had a longer duration of antecedent symptoms; however, none of these differences was statistically significant. All patients were febrile (greater than 38 degrees C) and appeared toxic. Similar proportions in each group had shock and disseminated intravascular coagulopathy at the time of admission. Ten of 12 patients with H influenzae infection compared with 15/30 (P less than .05) with meningococcal infection were lethargic or comatose at the time of admission. Nine of 12 patients with H influenzae infection died compared with 5/30 with meningococcal disease (P less than .005); the mean time from onset of symptoms to death with H influenzae infection (20.7 +/- 11.4 [SE] hours) was significantly shorter (P less than .05) than with meningococcal infection (120 +/- 74.4 hours). Children with clinical signs of sepsis and with purpura, petechiae, or coagulopathy may have N meningitidis or H influenzae as etiologic agents. Initial antibiotic therapy should be directed against these pathogens.

[Etiologic and pathogenetic factors in Waterhouse-Friderichsen syndrome (author's transl)]

The Waterhouse-Friderischsen syndrome (WFS) is the morphological substrate of a rapidly, mostly irreversible shock due to endotoxemia similar to the Sanerelli-Shwartzman phenomenon. The following disturbances of microcirculation cause death. The findings of 13 postmortem examinations reveal that acute severe respiratory infections, especially of nose and throat as etiologic factors, are more frequent than meningitis. Apparently different pathogens and shock vary the couse of disease and symptomatology before death. Moreover, because of the rarity and intensity of the WFS, as yet unknown or unrecognized dispositional factors cannot be ruled out.

Waterhouse-Friderichsen syndrome caused by a DF-2 bacterium in a splenectomised patient

A case of Waterhouse-Friderichsen syndrome associated with septicaemia caused by a DF-2 group bacterium (dysgonic fermenter--type 2--Atlanta classification) is presented. Attention is drawn to the relation of DF-2 group septicaemias to dog bites (or contact) and impaired host defence after splenectomy.

[Smallpox vaccination--Waterhouse-Friderichsen syndrome (author's transl)]

A fatal acute meningococcal sepsis (Waterhouse-Friderchsen syndrome) appearing 25 days after smallpox vaccination (re-vaccination) on military service is reported. In order to assume a causal connection between the vaccination reaction and the acute infectious complication on atypically long "unspecific negative phase" after the vaccination is postulated. The morphological findings at the vaccination pustule, which shows the same changes as a first vaccination, also support a pathological post-vaccinal course. In consideration of these observations, revaccination after 20 years is apparently a risk.